CR365 Pre-existing conditions Disability benefit claim
Disability benefit claim; pre-existing conditions clause does not cover complainant’s condition
1. The complainant had two policies, being a Personal Loan Protection Plan and a Credit Card Protection Plan, both these policies covering, inter alia, permanent disability.
2. The complainant was diagnosed with gout and arthritis a few weeks prior to the commencement of the two policies, and he became permanently disabled to perform his duties as a panel beater and a motor vehicle mechanic, some months after the commencement of the policies.
3. He submitted claims to the insurer under both the policies, which were declined on the basis of the exclusion of the pre-existing conditions, namely gout and arthritis.
4. The exclusion relied on was set out in the following provision in the policies (the wording of these policies were almost identical):
“X insurer will not pay any claim in the first 12 months after the start (or reinstatement) of cover because of any pre-existing condition you had when cover started. Pre-existing conditions are:
a. Any form of any of the following medical conditions (except for minor sickness, for example common cold or flu) that I(sic) have seen a medical doctor about or been treated for:
• heart disease or heart attack…;
• kidney disease;
• depression, epilepsy or fit;
• pneumonia, asthma, TB…
• disability; and
b. The usage of any form of chronic (long-term) medication continuously for at least six months;
c. Having had any special test (like a scan or X-ray) that was reported as abnormal and required medical treatment;
d. Any treatment during the past 12 months for any form of back-illness, hip, knee or shoulder problem;”.
5. The policies define “pre-existing conditions” clearly stating, “pre-existing conditions are” (own emphasis) in four categories. Only paragraph c of the definition of “pre-existing conditions” is relevant in this matter. With reference to the clause above, the view of the office was:
5.1 Gout and arthritis are not listed as pre-existing conditions – the clause specifically narrows down the conditions setting out…”pre-existing conditions are…any of the following…” and there is no reference to gout or arthritis or similar condition.
5.2 There was no proof of the complainant having used chronic medication.
5.3 The complainant had a blood test at Lancet Laboratories prior to the inception of the policies and the results showed that he had gout and rheumatoid arthritis. If one combines the requirement of causation in paragraph 4 above, with paragraph c of the definition, the test would look as follows:
“X insurer will not pay any claim in the first 12 months which is caused by a condition for which you had a special test done and the result of which was reported as abnormal and which required medical treatment.”
Paragraph c requires more than a diagnosis in that not only must the result be abnormal, it goes further by adding “and required medical treatment”.
For purposes of considering this paragraph, it could be accepted that:
• The tests done at the Lancet Laboratories were “special tests”.
• The result of gout and arthritis were “abnormal”.
• The next question would be if the complainant required medical treatment. There was no proof submitted that the complainant’s doctor prescribed any form of treatment or that the conditions were so severe that he should have been medically treated. In fact, the information at hand was that the complainant’s doctor did not even discuss the test results with him. The insurer, that had the onus to prove that a pre-existing condition prevailed, was unable to show that the provisions of paragraph c were met.
5.4 The complaint’s condition also did not fall within paragraph d of the definition because there was no indication of him having suffered from “any form of back-illness, hip, knee or shoulder problem”.
6. In terms of medical evidence submitted, the complainant fell within the requirements of permanently disabled. The insurer was requested to consider the claims against both policies.
7. The insurer made further enquiries with the complainant’s doctor to ascertain if he required medical treatment for his gout and arthritis after the tests were done. The doctor subsequently submitted a note stating that after the positive diagnosis had been made, the patient did not return for treatment. The insurer was further of the view that if the complainant had returned for treatment, the cause of his disability some months later, may have been avoided.
8. The office obtained an independent medical opinion on the treatment of gout and arthritis and was advised that medical treatment is not always required after a positive diagnosis as some people prefer lifestyle changes, such a dietary and exercise options, instead of medication, and if the condition is not chronic, there may be a tendency to defer medical treatment until the condition becomes chronic.
9. The insurer responded by admitting the claims against both policies and paid the outstanding balances in terms of the policies’ provisions in the case of permanent disablement.